Future Therapies: Uterus Transplant

There’s been a lot of “firsts” in reproductive technology recently and I will cover another one of them today. Last weekend, at Sweden’s University of Gothenburg, two moms donated their uteri to their daughters in uterine transplant procedures. In each case, the hope is that by surgically transplanting the mother’s uterus into her daughter, the daughter would then be able to become pregnant using the daughter’s embryos cryopreserved from earlier IVF procedures. One daughter lost her uterus to cancer; the other was born without a uterus. All four women were reported as recovering well after the surgeries. In 2000, in Saudi Arabia, the first uterine transplant was performed but the uterus was removed three weeks after the transplant after a blood clot developed. Last year, Turkish doctors reported the transplant of a uterus from a cadaver to a recipient but it is unclear whether the recipient has tried IVF after the transplant.

In June 2012, Mats Brannstrom, MD, PhD and colleagues wrote a review published in Fertility and Sterility called, “Uterus transplantation: animal research and human possibilities“, which discusses the research efforts in animals (mouse, rat, sheep, pig, baboon, macaque), most of which came after the first failed attempt at human uterine transplant. Factors that can cause the transplant to fail include surgical problems during either surgery to remove or transplant the uterus, vascular damage causing cell death (ischemia-reperfusion damage ) , rejection and side- effects from life-long use of immunosuppressive medication. Michael Olausson, one of the co-authors of the above paper was also one of the Swedish surgeons who performed last weekend’s surgery. “We are not going to call it a complete success until this results in children,” said Michael Olausson, one of the Swedish surgeons interviewed by The Associated Press.

The hospital has issued a video in which the surgeons, researchers and lab scientists on the transplant research team talk about their groundbreaking research. It’s an interesting piece. So we’ll have to stay tuned to see if these transplants work and children are born. Even if these surgeries work, we’ll have to see how well the recipients do with a long term immunosuppression regime. Presumably, when their reproductive effort are behind them, they could remove the transplant and discontinue immunosuppresents. Because these transplants are considered elective –compared to say, heart or liver transplants– there usually exists a higher standard for what constitutes acceptable risk for this experimental protocol.

Of course, with every new technology comes new ethical questions and Art Caplan, the “go-to” pundit for any reproductive ethics concerns is always happy to weigh-in regarding any new advance. So we have his take on uterus transplantation in this article (quoted below).

“There’s a lot going on in reproductive technology, but very little attention being paid by policy makers. Questions about who can use these techniques, who can donate a uterus, are all pretty much left to the marketplace,” Caplan said.

The U.S. has little in the way of legislation when it comes to assisted reproduction. Caplan believes that this is because the country is being “paralyzed by the abortion debate.”

“No politician wants to go near reproductive technology,” he said. “You’re sidling up to the abortion debate when you talk about embryos.”

Art Caplan got a few things right. IVF as practiced in the US is largely regulated by the marketplace,with relatively little (compared to other countries) federal or state regulations governing the practice of IVF. There is also no real NIH research budget for improving IVF techniques. Patients paying for services are commonly the guinea pigs for advances. so often new procedures are offered in the absence of little or no long term outcome data.

Caplan goes on to worry that if more and more women are able to have their own biological children, fewer childless couples would go the adoption route or as Caplan says. “Some people think spending large sums of money to perfect reproductive technology makes little sense when you have so many children that can’t find a home”.

Adoption is a very valid choice and there are many good reasons to adopt. Because you are solving a problem for society is probably the worst reason to adopt and it seems dim-witted that fertile people keep pushing this “duty” on infertile couples. Adopt because you want to adopt a child, not because society (or Art Caplan) thinks you should. Furthermore, unless we outlaw IVF completely (which is the goal of some groups), we should do everything we can to perfect reproductive technology if we are going to offer it to patients. Uterus transplant is just the newest innovation that may restore fertility for some women.

I was done with this post until I came across another pundit’s view on why uterine transplant is “troubling”. Lisa Belkin, Senior Columnist for life, work, family at HuffPost-Family describes her reservations about uterine transplant in her column “Giving Birth With A Borrowed Womb Does Not Make You A Mother”. I think the core of her concern in her own words is this: “Let’s forget for now the irony that giving birth post-transplant is the epitome of medicalized and unnatural, and look instead at the core of the belief that you need to carry a child to mother one. That dismisses the bonds between adoptive parents and children. It also dismisses the role of fathers. And it burdens far too may mothers, in that it takes us one step further along the spectrum that has women feeling “less-than” because they had a c-section or asked for an epidural. What technology should be giving us instead is affirmation of the fact that there are countless ways to have a baby, and that all of them are essentially irrelevant to actually becoming a parent.”

This whole line of reasoning appears to suggest that some people feel that their reproductive choices are made less valid because other people make different choices. How in the world can one woman’s choice to undergo a uterine transplant (or IVF for that matter) invalidate or devalue another woman’s choice to forgo technology and adopt?

She seems to be saying that merely having the option of uterine transplant on the menu will make women feel inferior to other uterus-less (or uterus-impaired?) women if they choose not to have a transplant but instead choose to adopt or use a surrogate. She worries that women who choose technology (c-section or epidural are her examples) are made to feel less woman-ly because they didn’t choose natural childbirth so obviously (?), let’s have less choices so we can all feel really good about having the “same” choice. What?? It reminds me of the tiresome “who is the better mother?” debate– the stay-at-home or working mom? The answer is both or either, it depends on the woman!

I think the discussion we should be having is that ALL women should feel good about however they create their families. More choice, not less choice, is empowering to women. Having lots of options for how to make a family increases the chances that women can have an option to choose what works best for them and their families.